Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

The Sr. Provider Contract Specialist is responsible for network development; negotiating, monitoring and managing the contractual relationship of assigned provider contracts. Working in coordination with Compliance, Provider Relations and Network Management, negotiates and finalizes provider contract language and rates, including amendments for existing contracts and establishment of new ones. Contracts for physician, hospital, ancillary and delegation of services for Medicaid and any other programs CHC may develop. Responsible for provider contract compliance. Coordinates with Network Management, Claims and Health Services to ensure adequate set up and comprehensive interpretation of new contract fees and requirements. Assists with provider profiling, working closely with Finance, Provider Relations, Member Services, Health Analysis and Health Services to provide reports, assist with analysis and recommend actions. Reviews quantitative analysis of various types of data including provider contracts, fee schedules, utilization and claims data needed for assessing, planning, budgeting, cost control and contract administration and makes recommendations for contracting rates and policies.

MINIMUM QUALIFICATIONS:

1. Education/Specialized Training/Licensure: Bachelor’s degree in healthcare administration, business or related field; Master’s Degree preferred. May substitute experience for education.

2. Work Experience (Years and Area): 7+ years in healthcare, with at least 5 years’ experience Providers / Managed Care, Contracting and Relations. STAR, STAR+PLUS,CHIP,CHIP Perinatal, MMP, Marketplace Medicare (preferred)

3. Management Experience (Years and Area): N/A

4. Equipment Operated: PC and own transportation

SPECIAL REQUIREMENTS:
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Bilingual Skills Required? No
Writing /Composing Correspondence / Reports

2. Other Skills:
Analytical Medical Terms Statistical
P.C. MS Word MS Excel

4. Work Schedule: Flexible

5. Other Requirements: Must have car and valid Texas Driver’s license. Must have managed care contract negotiation experience, preferably in Houston market.

Application Instructions

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